Businesses - Sponsors and Providers

D.2a Menu Survey

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OMB Control No: 0584-XXXX

OMB Approval Expiration Date: XX/XX/XXXX

Study of Nutrition and Activity in Child Care Settings (SNACS)

Menu Survey

Child Care Center ID

Target Week

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX .The time required to complete this information collection is estimated to average 20 minutes per response, per day (for five consecutive weekdays), including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

About the Study. The Study of Nutrition and Activity in Child Care Settings (SNACS) is intended to study nutrition and activity in child care centers, family day care homes, afterschool programs, and at-risk programs participating in the Child and Adult Care Food Program (CACFP) and some not participating in the CACFP. More than 1,500 child care providers in over 20 states were selected to be part of the study. Abt Associates is conducting this study for the USDA Food and Nutrition Service (FNS). Participation in the study by selected sponsors and child care providers who receive CACFP funds is required under Section 305 of the Healthy, Hunger-Free Kids Act of 2010 (HHFKA).

About this Survey. The purpose of the Menu Survey is to collect information about all of the foods offered to children in your child care facility during the assigned target week. An overview of the booklet is included on the next page.

Protecting Privacy. All information gathered from child care sponsors, child care centers, family day care homes, child care administrators and staff, and families participating in this study is for research purposes only and will be kept private to the full extent allowed by law except for general geographic location. Responses will be grouped with those of other study participants, and no individual participants, program administrators, program staff, parents, or children will be identified in any study report. Being part of the study will not affect any USDA benefits received by programs or families participating in this data collection.

Questions. If you have any questions about the study please call our toll-free study number at 1-844-808-4777 or email [email protected]. We will be happy to answer your questions and to help you in any way we can.

Thank you for participating in the Study of Nutrition and Activity in Child Care Settings (SNACS)

Menu Survey Overview

This survey should be completed by the person most familiar with food preparation at your child care center or home. In some child care settings, there is a person who prepares the food, and a different person who provides care to the children. We would like the food preparer to complete the form with information about what food is prepared, and how it is prepared.

This booklet is divided into the following sections:

Tab 1: Menu Survey Instructions – Please read all the instructions before you begin filling it out.

Tab 2: Daily Menus – Each daily section of this booklet is marked with a colored divider page (Monday, Tuesday, Wednesday, Thursday, Friday) and for each day, includes a set of Menu pages – one page for each type of meal or snack you may serve for that day. You may not need all the pages, but we have provided them in case you do.

Tab 3: Food You Prepared forms – You will use these pages to tell us more about foods you prepare by combining two or more ingredients.

Included with the Menu Survey is a separate booklet called the “Food Description Guide.” The booklet provides guidance for what details to include about each food listed on the Daily Menu pages.

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Tab 1

Instructions

This page has been left blank for double-sided printing

Menu Survey Instructions

Please use this booklet to describe all the foods and drinks you serve to children in child care/afterschool care during the week noted on the front cover.

You will be using the booklet for 5 consecutive weekdays (the Target Week), filling it in one page at a time as you prepare and serve meals and snacks, on each of the five days. You may not need to use all of the pages in the booklet, depending on how many meals and snacks you serve each day. There are extra pages for people who might need them.

Basic instructions for completing the survey are given below. There are also examples of completed forms facing the pages to be filled out, which can help guide you for completing the forms correctly.

Please read all of the instructions before you begin.

Printed Menu: We also ask that you provide a copy of your weekly or monthly menu that you may provide to parents. Please include this printed copy with your completed Menu Survey booklet.

If you have any questions at any time please call our toll-free number at 1-844-808-4777. We will be happy to answer your questions and to help you in any way we can.

Someone from Abt Associates will be calling you soon to make sure you received the survey and to answer any questions you may have before you begin filling it out.

Thank you very much for your help with this important study.

The following pages provide instructions for each section of the booklet.

How to fill out the Daily Menu Pages

(Tab 2 of this booklet)

Each day, you will fill out the pages in the section of the booklet marked with the name of that day: Monday, Tuesday, Wednesday, Thursday, and Friday (colored divider page will indicate a new day).

When reviewing the Daily Menu pages, you will see that each Daily section of the Daily Menus includes a menu form for food and beverages served during:

• Breakfast

• Morning Snack

• Lunch

• Afternoon Snack

• Supper

• Evening Snack

Use a separate form for each meal or snack you serve on each day.

T he top of each form will look like the example here, with the meal or snack listed at the top.

1. Please provide the Date and Day of the Week for which you are filling out the page.

There is also an option to check off a box if the meal on that page was not served that day. The example here is for breakfast. If you did not serve breakfast that day, you would select this box and leave the rest of that form blank.

Checking this box will show us that you did not overlook filling in the daily menu for a meal.

2. At the top of each page you will also specify the type of service used during that meal:

Select the type of service that is used first during the meal. If you put food on the children’s plates at the beginning of the meal, then the child is allowed to take seconds on their own, this would be considered “Delivered in bulk and portioned by staff”.

• Select Delivered in bulk and portioned by staff if large serving dishes arrive in the classroom and then staff portion the plates for children on individual dishes or trays.

• Select Individually pre-portioned plates if individual dishes or trays arrive in the classroom already portioned for children, and staff passes them out.

• Select Family Style if the serving dishes are on a community table at the beginning of service and children self-serve.

• Select Other if you use a different method of service not described above. Please use the space provided to describe your food service method.

Filling out the rest of the form:

For every meal and snack served each day, please fill in the form to tell us all food and drink items that you served. Follow the instructions at the top of each column:

3. List Each Food and Drink Served at this Meal

• W rite down all of the foods and drinks you served for that meal or snack.

• List each food or drink under the food category it belongs to:

  • Milk

  • Fruit/Vegetable

  • Grain/Bread

  • Meat/Meat Alternate and Mixed Component Foods

  • Other

If you are unsure of which category a food you served belongs to, write it in the “Other” category.

Juice: You can enter information for juices served to children under the “Fruits, Vegetables, and Fruit/Vegetable Juice” category.

Also note in the Please Describe Each Food or Drink column if the juice is 100% juice, fortified, from concentrate, etc. You can find examples of how to record this information on the Example pages, as well as in the Food Description Guide.

NOTE: Please only list foods and beverages provided to the majority of children in your care. If you prepare alternate meals for children with dietary restrictions, you do not need to include these items on the Daily Menus.

4. Please Describe Each Food or Drink

• D escribe each food and drink in detail. Include details such as brand name or manufacturer and type or flavor variety of food.

• The pamphlet labeled “FOOD DESCRIPTION GUIDE” lists the kinds of details we need you to write down in this column for different types of foods and beverages you serve.

• For milk, check the box for the appropriate type of milk (e.g. skim, 1%, 2%, whole) and list the flavor (e.g., white, chocolate)

• If you receive foods that are prepared off-site (such as a vendor or school district), please ask your representative if they can provide the necessary details about the foods you list on the daily menu pages.

5. Food Preparation: Foods You Prepared

• I f you prepared the food by combining two or more ingredients, check the box for each food and drink you list. The checkmark will tell us that the food was prepared by you, and that you filled out a “Foods You Prepared” form.

You do not need to fill out a Foods You Prepared form for any foods which need little or no preparation on your part, or can be eaten as is. This includes food that only needs to be heated to be served. Fresh fruits and vegetables that have been cut into pieces by staff do not require a Foods You Prepared form.

The chart below provides examples of when to fill out a “Foods You Prepared” form and when it is not needed.

Use the Foods You Prepared form	DO NOT Use the Foods You Prepared form
Rice you cooked	Commercially prepared applesauce
Baby food with 2 or more ingredients prepared by you	Frozen chicken nuggets (heated)
Leftover foods mixed with additional foods	Banana slices
Hot cereal with any additions (cinnamon, raisins, etc.)	Packaged crackers
Sandwiches	Diced cheese
Macaroni and Cheese	Cold cereal with milk (this would be listed on two separate lines; one line for milk, one line for cereal in the grain/bread section.)

Important to Note: If you are able to provide a printed copy of the recipe, and it has all of the information that we ask for on the Foods You Prepared form, you do not need to fill out the Foods You Prepared form. Instead, please attach the printed recipe to the form. If there are any revisions to the recipe, please write them on the recipe.

If you do not have a copy of the recipe, please fill out a page in the Foods You Prepared form located at the back of the booklet behind the Foods You Prepared tab. Use one Foods You Prepared form for each recipe.

6. Age Group(s) Served

• Check the boxes to tell us the ages of the children to whom each food or drink was served. If your child care center or home does not serve a certain age group listed on the form, please leave the column blank.

• If served to multiple age groups, select all that were served that item.

• I f different types of the same food (for example, different types of milk) were served for different ages of children, you should list the different type of food on a separate row, and select the age group receiving the specified food.

Please also note the following:

Water: If water is served specifically as a beverage that goes with the meal or snack, rather than just being available in the room please include it on the form as an item that was served. Write this in under the “Other” category, and describe how it was provided.

Filling out the Foods You Prepared Form

(Tab 3 of this booklet)

Please fill out one of these forms for any food you checked off as Foods You Prepared on the Daily Menu forms, unless you can provide a printed recipe. This should include any food you made from scratch or prepared by combining two or more foods or ingredients. A sample, completed Foods You Prepared Form is shown behind Tab 3 (Foods You Prepared Forms).

If you receive foods that are prepared off-site (such as a vendor or school district), please ask your representative if they can provide a recipe for foods that they prepare from scratch or by combining two or more ingredients. Attach the recipe to the form in this booklet and indicate the details described in 1-4 below on the form.

How to Fill in the Foods You Prepared Form

1. Name of the Food: Write the name of the food in the space provided at the top of the page. Please use the same name you used on the Menu page in Tab 2.

2. Number of Servings Prepared: Write down the number of servings you made.

3. Size of each Serving: Write down the size of each serving (for example, ½ cup, 4 oz. 1 sandwich, etc.)

4. When was Food Served?: Check the box beside the meal or meals at which the food was served. Write in the dates the food was served during the target week.

5. Fill in the chart using the instructions at the top of each column:

What Ingredients or Foods Did You Use?

• List each ingredient and food by name on separate line. Include everything you used including salt, added fats like butter, margarine, mayonnaise, and oil, pan drippings, water and stock.

How Much Did You Use?

• Show the amount of each ingredient or food you used. Be sure to write both the number and the type of measurement:

Examples:

• 2 Tbsp. mayonnaise

• 2 tsp. salt

• 4 oz. shredded cheese

• 2 pounds (lb.) ground beef

• ¾ cup cooked rice

• 1 quart (qt.) milk

• If you use an ingredient that is not measured, write down how much or many you used, If possible, write whether the item was small, regular (medium), or large.

Examples:

• 1 large carrot

• ½ large green pepper

• 15 crackers (saltine size)

• 3 small bananas

• 2 regular slices bread

• 8 squares graham crackers

6. Please Describe Each Ingredient or Food

• Use this column to describe each ingredient or food in detail. Look for the ingredient or food in the Food Description Guide to see the kinds of information to write for each ingredient or food (brand, type, flavor, etc.)

• Be sure to write whether it was raw or cooked, shredded, chopped, sliced, ground, grated, crushed or whole.

6. Preparation and Cooking Method (if Applicable)

• Answer questions 1, 2 and 3 if they apply to the food you prepared.

• Question 4 asks about salt added during the cooking process, such as salt added to cooking water, rather than an ingredient in the recipe.

Tab 2

Daily Menus

Example of Completed Menu for Breakfast

Today’s Date: __2/8/16____________ Day of Week:  Monday  Tuesday  Wednesday  Thursday  Friday

 Check this box if you did not serve breakfast

Type of Meal Service:  Delivered in bulk and portioned by staff  Individually pre-portioned plates  Family Style  Other (describe):______________

List Each Food and Drink Served at this meal	Please Describe Each Food or Drink For detailed information on what to include in this column, including brand, type, and preparation method, please refer to the Food Description Guide.	Food Preparation	Age Group(s) Served Check the box(es) for each age group to whom you served the food or drink
		Foods You Prepared*	1 year	2 years	3-5 years	6-12 years
Milk
Milk	 Skim  1%  2%  Whole Flavor:_________					
Milk	 Skim  1%  2%  Whole Flavor:_________					
						
Fruit / Vegetable
Applesauce	Motts: unsweetened					
Orange Juice	Tropicana, calcium fortified					
						
						
Grain / Bread
Oatmeal	Quick oats					
Pancakes	Whole wheat					
Cereal	General Mills, Honey Nut Cheerios					
						
Meat/Meat Alternate and Mixed Component Foods
						
						
						
Other
						
						
						

Menu for Breakfast

Today’s Date: ___________________________ Day of Week:  Monday  Tuesday  Wednesday  Thursday  Friday

 Check this box if you did not serve breakfast

Type of Meal Service:  Delivered in bulk and portioned by staff  Individually pre-portioned plates  Family Style  Other (describe):_____________

List Each Food and Drink Served at this meal	Please Describe Each Food or Drink For detailed information on what to include in this column, including brand, type, and preparation method, please refer to the Food Description Guide.	Food Preparation	Age Group(s) Served Select the column(s) for each age group to whom you served the food or drink
		Foods You Prepared*	1 year	2 years	3-5 years	6-12 years
Milk
Milk	 Skim  1%  2%  Whole Flavor:_____________					
Milk	 Skim  1%  2%  Whole Flavor:_____________					
						
Fruit / Vegetable
						
						
						
						
Grain / Bread
						
						
						
						
Meat/Meat Alternate and Mixed Component Foods
						
						
						
						
Other
						
						
						
						

Example of Completed Menu for Morning Snack

Today’s Date: ____2/8/16___________ Day of Week:  Monday  Tuesday  Wednesday  Thursday  Friday

 Check this box if you did not serve morning snack

Type of Meal Service:  Delivered in bulk and portioned by staff  Individually pre-portioned plates  Family Style  Other (describe):_____________

List Each Food and Drink Served at this meal	Please Describe Each Food or Drink For detailed information on what to include in this column, including brand, type, and preparation method, please refer to the Food Description Guide.	Food Preparation	Age Group(s) Served Select the column(s) for each age group to whom you served the food or drink
		Foods You Prepared*	1 year	2 years	3-5 years	6-12 years
Milk
Milk	 Skim  1%  2%  Whole Flavor:_________					
Milk	 Skim  1%  2%  Whole Flavor:_________					
						
Fruit / Vegetable
Banana	Fresh, sliced					
Raisins	Sun Maid					
						
						
Grain / Bread
Graham Crackers	Mi-Del, Whole Grain, Cinnamon					
						
						
						
Meat/Meat Alternate and Mixed Component Foods
Sunflower seed spread	Sun butter					
						
						
						
Other
						
						
						
						

Menu for Morning Snack

Today’s Date: ___________________________ Day of Week:  Monday  Tuesday  Wednesday  Thursday  Friday

 Check this box if you did not serve morning snack

Type of Meal Service:  Delivered in bulk and portioned by staff  Individually pre-portioned plates  Family Style  Other (describe):_____________

List Each Food and Drink Served at this meal	Please Describe Each Food or Drink For detailed information on what to include in this column, including brand, type, and preparation method, please refer to the Food Description Guide.	Food Preparation	Age Group(s) Served Select the column(s) for each age group to whom you served the food or drink
		Foods You Prepared*	1 year	2 years	3-5 years	6-12 years
Milk
Milk	 Skim  1%  2%  Whole Flavor:_____________					
Milk	 Skim  1%  2%  Whole Flavor:_____________					
						
Fruit / Vegetable
						
						
						
						
Grain / Bread
						
						
						
						
Meat/Meat Alternate and Mixed Component Foods
						
						
						
						
Other
						
						
						
						

Example of Completed Menu for Lunch

Today’s Date: ____2/8/16___________ Day of Week:  Monday  Tuesday  Wednesday  Thursday  Friday

 Check this box if you did not serve lunch

Type of Meal Service:  Delivered in bulk and portioned by staff  Individually pre-portioned plates  Family Style  Other (describe):_____________

List Each Food and Drink Served at this meal	Please Describe Each Food or Drink For detailed information on what to include in this column, including brand, type, and preparation method, please refer to the Food Description Guide.	Food Preparation	Age Group(s) Served Select the column(s) for each age group to whom you served the food or drink
		Foods You Prepared*	1 year	2 years	3-5 years	6-12 years
Milk
Milk	 Skim  1%  2%  Whole Flavor:_________					
Milk	 Skim  1%  2%  Whole Flavor:_________					
						
Fruit / Vegetable
Apple	Granny Smith, sliced					
Broccoli	Spears, steamed, from frozen					
						
						
Grain / Bread
						
						
						
						
Meat/Meat Alternate and Mixed Component Foods
Bean & Cheese Quesadilla	Whole grain tortilla, cheddar cheese, black beans					
						
						
						
Other
						
						
						
						

Menu for Lunch

Today’s Date: ___________________________ Day of Week:  Monday  Tuesday  Wednesday  Thursday  Friday

 Check this box if you did not serve lunch

Type of Meal Service:  Delivered in bulk and portioned by staff  Individually pre-portioned plates  Family Style  Other (describe):_____________

List Each Food and Drink Served at this meal	Please Describe Each Food or Drink For detailed information on what to include in this column, including brand, type, and preparation method, please refer to the Food Description Guide.	Food Preparation	Age Group(s) Served Select the column(s) for each age group to whom you served the food or drink
		Foods You Prepared*	1 year	2 years	3-5 years	6-12 years
Milk
Milk	 Skim  1%  2%  Whole Flavor:_____________					
Milk	 Skim  1%  2%  Whole Flavor:_____________					
						
Fruit / Vegetable
						
						
						
						
Grain / Bread
						
						
						
						
Meat/Meat Alternate and Mixed Component Foods
						
						
						
						
Other
						
						
						
						

Example of Completed Menu for Afternoon Snack

Today’s Date: ____2/8/16___________ Day of Week:  Monday  Tuesday  Wednesday  Thursday  Friday

 Check this box if you did not serve afternoon snack

Type of Meal Service:  Delivered in bulk and portioned by staff  Individually pre-portioned plates  Family Style  Other (describe):_____________

List Each Food and Drink Served at this meal	Please Describe Each Food or Drink For detailed information on what to include in this column, including brand, type, and preparation method, please refer to the Food Description Guide.	Food Preparation	Age Group(s) Served Select the column(s) for each age group to whom you served the food or drink
		Foods You Prepared*	1 year	2 years	3-5 years	6-12 years
Milk
Milk	 Skim  1%  2%  Whole Flavor:__________					
Milk	 Skim  1%  2%  Whole Flavor:__________					
						
Fruit / Vegetable
Carrots	Baby carrots, fresh					
Orange	Sectioned, fresh					
						
						
Grain / Bread
Goldfish	Pepperidge Farm: Cheddar					
						
						
						
Meat/Meat Alternate and Mixed Component Foods
						
						
						
						
Other
Ranch dip	Kraft reduced fat (served w/ carrots)					
Water	From tap, in drinking cups					
						
						

Menu for Afternoon Snack

Today’s Date: ___________________________ Day of Week:  Monday  Tuesday  Wednesday  Thursday  Friday

 Check this box if you did not serve afternoon snack

Type of Meal Service:  Delivered in bulk and portioned by staff  Individually pre-portioned plates  Family Style  Other (describe):_____________

List Each Food and Drink Served at this meal	Please Describe Each Food or Drink For detailed information on what to include in this column, including brand, type, and preparation method, please refer to the Food Description Guide.	Food Preparation	Age Group(s) Served Select the column(s) for each age group to whom you served the food or drink
		Foods You Prepared*	1 year	2 years	3-5 years	6-12 years
Milk
Milk	 Skim  1%  2%  Whole Flavor:_____________					
Milk	 Skim  1%  2%  Whole Flavor:_____________					
						
Fruit / Vegetable
						
						
						
						
Grain / Bread
						
						
						
						
Meat/Meat Alternate and Mixed Component Foods
						
						
						
						
Other
						
						
						
						

Example of Completed Menu for Supper

Today’s Date: ____2/8/16___________ Day of Week:  Monday  Tuesday  Wednesday  Thursday  Friday

 Check this box if you did not serve supper

Type of Meal Service:  Delivered in bulk and portioned by staff  Individually pre-portioned plates  Family Style  Other (describe):_____________

List Each Food and Drink Served at this meal	Please Describe Each Food or Drink For detailed information on what to include in this column, including brand, type, and preparation method, please refer to the Food Description Guide.	Food Preparation	Age Group(s) Served Select the column(s) for each age group to whom you served the food or drink
		Foods You Prepared*	1 year	2 years	3-5 years	6-12 years
Milk
Milk	 Skim  1%  2%  Whole Flavor:__________					
Milk	 Skim  1%  2%  Whole Flavor:__________					
						
Fruit / Vegetable
Mixed Vegetables	Canned, mix of carrots, peas, cauliflower					
Grapes	Red table grapes - fresh					
Pear	Fresh, diced, peeled					
						
Grain / Bread
Dinner Roll	Bake Crafters Split top, Whole Grain					
Cookie	Nabisco: Vanilla Wafer					
						
						
Meat/Meat Alternate and Mixed Component Foods
Chicken Nuggets	Tyson: Home-style , Whole Grain , baked					
						
						
						
Other
BBQ Sauce	Kraft Original, Served with nuggets					
						
						
						

Menu for Supper

Today’s Date: ___________________________ Day of Week:  Monday  Tuesday  Wednesday  Thursday  Friday

 Check this box if you did not serve supper

Type of Meal Service:  Delivered in bulk and portioned by staff  Individually pre-portioned plates  Family Style  Other (describe):_____________

List Each Food and Drink Served at this meal	Please Describe Each Food or Drink For detailed information on what to include in this column, including brand, type, and preparation method, please refer to the Food Description Guide.	Food Preparation	Age Group(s) Served Select the column(s) for each age group to whom you served the food or drink
		Foods You Prepared*	1 year	2 years	3-5 years	6-12 years
Foods You Prepared*
Milk	 Skim  1%  2%  Whole Flavor:_____________					
Milk	 Skim  1%  2%  Whole Flavor:_____________					
						
Fruit / Vegetable
						
						
						
						
Grain / Bread
						
						
						
						
Meat/Meat Alternate and Mixed Component Foods
						
						
						
						
Other
						
						
						
						

Example of Completed Menu for Evening Snack

Today’s Date: ____2/8/16___________ Day of Week:  Monday  Tuesday  Wednesday  Thursday  Friday

 Check this box if you did not serve evening snack

Type of Meal Service:  Delivered in bulk and portioned by staff  Individually pre-portioned plates  Family Style  Other (describe):_____________

List Each Food and Drink Served at this meal	Please Describe Each Food or Drink For detailed information on what to include in this column, including brand, type, and preparation method, please refer to the Food Description Guide.	Food Preparation	Age Group(s) Served Select the column(s) for each age group to whom you served the food or drink
		Foods You Prepared*	1 year	2 years	3-5 years	6-12 years
Milk
Milk	 Skim  1%  2%  Whole Flavor:_________					
Milk	 Skim  1%  2%  Whole Flavor:_________					
						
Fruit / Vegetable
						
						
						
						
Grain / Bread
Crackers	Keebler, Multigrain club crackers					
						
						
						
Meat/Meat Alternate and Mixed Component Foods
Cheese	Cheddar cheese, cubed					
						
						
						
Other
						
						
						
						

Menu for Evening Snack

Today’s Date: ___________________________ Day of Week:  Monday  Tuesday  Wednesday  Thursday  Friday

 Check this box if you did not serve evening snack

Type of Meal Service:  Delivered in bulk and portioned by staff  Individually pre-portioned plates  Family Style  Other (describe):_____________

List Each Food and Drink Served at this meal	Please Describe Each Food or Drink For detailed information on what to include in this column, including brand, type, and preparation method, please refer to the Food Description Guide.	Food Preparation	Age Group(s) Served Select the column(s) for each age group to whom you served the food or drink
		Foods You Prepared*	1 year	2 years	3-5 years	6-12 years
Milk
Milk	 Skim  1%  2%  Whole Flavor:_____________					
Milk	 Skim  1%  2%  Whole Flavor:_____________					
						
Fruit / Vegetable
						
						
						
						
Grain / Bread
						
						
						
						
Meat/Meat Alternate and Mixed Component Foods
						
						
						
						
Other
						
						
						

This page has been left blank for double-sided printing

Tab 3

Foods You Prepared Form

Please fill out a Foods You Prepared Form for any food items with a checkbox in the “Food Preparation” column.

These are items made from two or more ingredients, served at the child care facility, listed on your Daily Menu pages.

Note: If you are able to provide a printed copy of the recipe, and it has all of the information that we ask for on the Foods You Prepared form, you do not need to fill out the Foods You Prepared form. Instead, please attach the printed recipe to the form. If there are any revisions to the recipe, please write them on the recipe.

Foods You Prepared

When Was Food Served?

Check all that apply and indicate date(s) served:

Date(s) Served:

 Breakfast _2/8/16______

 Morning Snack _______________

 Lunch _______________

 Afternoon Snack _______________

 Supper _______________

 Evening Snack _______________

Fill out one page for each food you made from scratch or made by combining two or more foods or ingredients (examples: sandwiches, chili, tuna salad, mashed potatoes, pancakes, etc.).

Name of Food: ____Pancakes _______________________

(Please use same name you used on the Daily Menus)

Number of Servings Prepared:_____25________________________

Size of each serving: One 4 inch pancake____________________

(Examples: ½ cup, 4fl. oz., 1 cup, 3 TBSP)

What Ingredients or Foods Did You Use? (List all ingredients and foods.)	How Much Did You Use? (Examples: 2 tsp, ½ cup, 1 pound, 4fl oz., etc.)	Please Describe Each Ingredient or Food. (Provide as much detail as possible. Check the Food Description Guide.)
Whole wheat flour	3 ¾ cups
Baking powder	2 TB
Salt	¾ tsp
Instant nonfat dry milk	½ cup
Sugar	2 TB 2 tsp	White, granulated
Eggs	5	Fresh eggs
Water	2.5 cups
Vegetable Oil	½ cup

Preparation and/or Cooking Method (If Applicable):

1. If cooked:

a. What cooking method did you use? (check one)

 Bake/Roast  Broil/Grill  Pan Fry/Sauté  Stir Fry  Deep Fry Boil/Parboil  Other (specify): griddle

b. What fat was added during the cooking process? (check one)

 Vegetable Oil  Olive Oil  Butter  Margarine  Other (specify)________  None

2. If you prepared meat (chicken, beef, pork, etc.), did you: (Check all that apply)

a. Trim the visible fat?  Yes  No  No visible fat to trim

b. Drain the fat after cooking?  Yes  No  No fat to drain

3. If you prepared fruit(s) or vegetable(s), did you:

1. a. Peel the fruit or vegetable?  Yes  No  No peel to remove

2. b. Mash or blend the fruit or vegetable?  Yes  No

4. Was salt added during the cooking process?  Yes  No

Foods You Prepared

When Was Food Served?

Check all that apply and indicate date(s) served:

Date(s) Served:

 Breakfast _______________

 Morning Snack _______________

 Lunch _______________

 Afternoon Snack _______________

 Supper _______________

 Evening Snack _______________

Fill out one page for each food you made from scratch or made by combining two or more foods or ingredients (examples: sandwiches, chili, tuna salad, mashed potatoes, pancakes, etc.).

Name of Food: _____________________________________________

(Please use same name you used on the Daily Menus)

Number of Servings Prepared:________________________________

Size of each serving:________________________________

(Examples: ½ cup, 4fl. oz., 1 cup, 3 TBSP)

What Ingredients or Foods Did You Use? (List all ingredients and foods.)	How Much Did You Use? (Examples: 2 tsp, ½ cup, 1 pound, 4fl oz., etc.)	Please Describe Each Ingredient or Food. (Provide as much detail as possible. Check the Food Description Guide.)

Preparation and Cooking Method (If Applicable):

1. If cooked:

a. What cooking method did you use? (check one)

 Bake/Roast  Broil/Grill  Pan Fry/Sauté  Stir Fry  Deep Fry Boil/Parboil  Other (specify): _______

b. What fat was added during the cooking process? (check one)

 Vegetable Oil  Olive Oil  Butter  Margarine  Other (specify)________  None

2. If you prepared meat (chicken, beef, pork, etc.), did you: (Check all that apply)

a. Trim the visible fat?  Yes  No  No visible fat to trim

b. Drain the fat after cooking?  Yes  No  No fat to drain

3. If you prepared fruit(s) or vegetable(s), did you:

3. a. Peel the fruit or vegetable?  Yes  No  No peel to remove

4. b. Mash or blend the fruit or vegetable?  Yes  No

4. Was salt added during the cooking process?  Yes  No

Foods You Prepared

When Was Food Served?

Check all that apply and indicate date(s) served:

Date(s) Served:

 Breakfast _______________

 Morning Snack _______________

 Lunch _______________

 Afternoon Snack _______________

 Supper _______________

 Evening Snack _______________

Fill out one page for each food you made from scratch or made by combining two or more foods or ingredients (examples: sandwiches, chili, tuna salad, mashed potatoes, pancakes, etc.).

Name of Food: _____________________________________________

(Please use same name you used on the Daily Menus)

Number of Servings Prepared:________________________________

Size of each serving:________________________________

(Examples: ½ cup, 4fl. oz., 1 cup, 3 TBSP)

What Ingredients or Foods Did You Use? (List all ingredients and foods.)	How Much Did You Use? (Examples: 2 tsp, ½ cup, 1 pound, 4fl oz., etc.)	Please Describe Each Ingredient or Food. (Provide as much detail as possible. Check the Food Description Guide.)

Preparation and Cooking Method (If Applicable):

1. If cooked:

a. What cooking method did you use? (check one)

 Bake/Roast  Broil/Grill  Pan Fry/Sauté  Stir Fry  Deep Fry Boil/Parboil  Other (specify): ______

b. What fat was added during the cooking process? (check one)

 Vegetable Oil  Olive Oil  Butter  Margarine  Other (specify)________  None

2. If you prepared meat (chicken, beef, pork, etc.), did you: (Check all that apply)

a. Trim the visible fat?  Yes  No  No visible fat to trim

b. Drain the fat after cooking?  Yes  No  No fat to drain

3. If you prepared fruit(s) or vegetable(s), did you:

5. a. Peel the fruit or vegetable?  Yes  No  No peel to remove

6. b. Mash or blend the fruit or vegetable?  Yes  No

4. Was salt added during the cooking process?  Yes  No

Foods You Prepared

When Was Food Served?

Check all that apply and indicate date(s) served:

Date(s) Served:

 Breakfast _______________

 Morning Snack _______________

 Lunch _______________

 Afternoon Snack _______________

 Supper _______________

 Evening Snack _______________

Fill out one page for each food you made from scratch or made by combining two or more foods or ingredients (examples: sandwiches, chili, tuna salad, mashed potatoes, pancakes, etc.).

Name of Food: _____________________________________________

(Please use same name you used on the Daily Menus)

Number of Servings Prepared:________________________________

Size of each serving:________________________________

(Examples: ½ cup, 4fl. oz., 1 cup, 3 TBSP)

What Ingredients or Foods Did You Use? (List all ingredients and foods.)	How Much Did You Use? (Examples: 2 tsp, ½ cup, 1 pound, 4fl oz., etc.)	Please Describe Each Ingredient or Food. (Provide as much detail as possible. Check the Food Description Guide.)

Preparation and Cooking Method (If Applicable):

1. If cooked:

a. What cooking method did you use? (check one)

 Bake/Roast  Broil/Grill  Pan Fry/Sauté  Stir Fry  Deep Fry Boil/Parboil  Other (specify): _______

b. What fat was added during the cooking process? (check one)

 Vegetable Oil  Olive Oil  Butter  Margarine  Other (specify)________  None

2. If you prepared meat (chicken, beef, pork, etc.), did you: (Check all that apply)

a. Trim the visible fat?  Yes  No  No visible fat to trim

b. Drain the fat after cooking?  Yes  No  No fat to drain

3. If you prepared fruit(s) or vegetable(s), did you:

7. a. Peel the fruit or vegetable?  Yes  No  No peel to remove

8. b. Mash or blend the fruit or vegetable?  Yes  No

4. Was salt added during the cooking process?  Yes  No

Foods You Prepared

When Was Food Served?

Check all that apply and indicate date(s) served:

Date(s) Served:

 Breakfast _______________

 Morning Snack _______________

 Lunch _______________

 Afternoon Snack _______________

 Supper _______________

 Evening Snack _______________

Fill out one page for each food you made from scratch or made by combining two or more foods or ingredients (examples: sandwiches, chili, tuna salad, mashed potatoes, pancakes, etc.).

Name of Food: _____________________________________________

(Please use same name you used on the Daily Menus)

Number of Servings Prepared:________________________________

Size of each serving: ________________________________

(Examples: ½ cup, 4fl. oz., 1 cup, 3 TBSP)

What Ingredients or Foods Did You Use? (List all ingredients and foods.)	How Much Did You Use? (Examples: 2 tsp, ½ cup, 1 pound, 4fl oz., etc.)	Please Describe Each Ingredient or Food. (Provide as much detail as possible. Check the Food Description Guide.)

Preparation and Cooking Method (If Applicable):

1. If cooked:

a. What cooking method did you use? (check one)

 Bake/Roast  Broil/Grill  Pan Fry/Sauté  Stir Fry  Deep Fry Boil/Parboil  Other (specify): _______

b. What fat was added during the cooking process? (check one)

 Vegetable Oil  Olive Oil  Butter  Margarine  Other (specify)________  None

2. If you prepared meat (chicken, beef, pork, etc.), did you: (Check all that apply)

a. Trim the visible fat?  Yes  No  No visible fat to trim

b. Drain the fat after cooking?  Yes  No  No fat to drain

3. If you prepared fruit(s) or vegetable(s), did you:

9. a. Peel the fruit or vegetable?  Yes  No  No peel to remove

10. b. Mash or blend the fruit or vegetable?  Yes  No

4. Was salt added during the cooking process?  Yes  No

Foods You Prepared

When Was Food Served?

Check all that apply and indicate date(s) served:

Date(s) Served:

 Breakfast _______________

 Morning Snack _______________

 Lunch _______________

 Afternoon Snack _______________

 Supper _______________

 Evening Snack _______________

Fill out one page for each food you made from scratch or made by combining two or more foods or ingredients (examples: sandwiches, chili, tuna salad, mashed potatoes, pancakes, etc.).

Name of Food: _____________________________________________

(Please use same name you used on the Daily Menus)

Number of Servings Prepared:________________________________

Size of each serving: ________________________________

(Examples: ½ cup, 4fl. oz., 1 cup, 3 TBSP)

What Ingredients or Foods Did You Use? (List all ingredients and foods.)	How Much Did You Use? (Examples: 2 tsp, ½ cup, 1 pound, 4fl oz., etc.)	Please Describe Each Ingredient or Food. (Provide as much detail as possible. Check the Food Description Guide.)

Preparation and Cooking Method (If Applicable):

1. If cooked:

a. What cooking method did you use? (check one)

 Bake/Roast  Broil/Grill  Pan Fry/Sauté  Stir Fry  Deep Fry Boil/Parboil  Other (specify): _______

b. What fat was added during the cooking process? (check one)

 Vegetable Oil  Olive Oil  Butter  Margarine  Other (specify)________  None

2. If you prepared meat (chicken, beef, pork, etc.), did you: (Check all that apply)

a. Trim the visible fat?  Yes  No  No visible fat to trim

b. Drain the fat after cooking?  Yes  No  No fat to drain

3. If you prepared fruit(s) or vegetable(s), did you:

11. a. Peel the fruit or vegetable?  Yes  No  No peel to remove

12. b. Mash or blend the fruit or vegetable?  Yes  No

4. Was salt added during the cooking process?  Yes  No

Menu Survey, p. 1